A Critical Appraisal Of A Qualitative Journal Article Nursing Essay

Research is a significant element in all professions, but perhaps

This essay will present a reflective account of communication skills in practice whist undertaking assessment and history taking of two Intensive Care patients with a similar condition. It will endeavour to explore all aspects of non verbal and verbal communication styles and reflect upon these areas using Gibbs reflective cycle (1988).

Scenario A –

Mrs James, 34, a passenger in a road traffic collision who was not wearing a seatbelt was thrown through the windscreen resulting in multiple facial wounds with extensive facial swelling which required her to be intubated and sedated. She currently has cervical spine immobilisation and is awaiting a secondary trauma CT. Mr James was also involved in the accident.

Scenario B –

Mr James, 37, husband of Mrs James, the driver of the car, was wearing his seat belt. He had minor superficial facial wounds, fractured ribs and a fractured right arm. He is alert and orientated but currently breathless and requiring high oxygen concentrations.

Patients who are admitted to Intensive Care are typically admitted due to serious ill health or trauma that may also have a potential to develop life threatening complications (Udwadia, 2005). These patients are usually unconscious, have limited movement and have sensation deprivation due to sedation and/or disease processes. These critical conditions rely upon modern technical support and invasive procedures for the purpose of monitoring and regulation of physiological functions. Having the ability to effectively communicate with patients, colleagues and their close relatives is a fundamental clinical skill in Intensive Care and central to a skilful nursing practice. Communication in Intensive Care is therefore of high importance (Elliot, 1999) to provide information and support to the critically ill patient in order to reduce their anxieties, stresses and preserve self identity, self esteem and reduce social isolation (João: 2009, Alasad: 2004, Newmarch:2006). Effective communication is the key to the collection of patient information, delivering quality of care and ensuring patient safety.

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Gaining a patients history is one of the most important skills in medicine and is a foundation for both the diagnosis and patient – clinician relationship, and is increasingly being undertaken by nurses (Crumbie, 2006). Commonly a patient may be critically ill and therefore the ability to perform a timely assessment whilst being prepared to administer life saving treatment is crucial (Carr, 2005). Often the patient is transferred from a ward or department within the hospital where a comprehensive history has been taken with documentation of a full examination; investigations, working diagnosis and the appropriate treatment taken. However, the patient’s history may not have been collected on this admission if it was not appropriate to do so. Where available patients medical notes can provide essential information.

In relation to the scenarios where the patient is breathless or the patient had a reduced conscious level and requires sedation and intubation, effective communication is restricted and obtaining a comprehensive history would be inappropriate and almost certainly unsafe. The Nursing Midwifery Council promotes the importance of keeping clear and accurate records within the Code: Standards of Conduct, performance and ethics for nurses and midwives (NMC, 2008). Therefore if taking a patients history is unsafe to do so, this required to be documented.

Breathing is a fundamental life process that usually occurs without conscious thought and, for the healthy person is taken for granted (Booker, 2004). In Scenario A, Mrs James’s arrived on Intensive care and was intubated following her facial wounds and localised swelling. Facial trauma by its self is not a life threatening injury, although it has often been accompanied with other injuries such as traumatic brain injury and complications such as airway obstruction. This may have been caused by further swelling, bleeding or bone structure damage (Parks, 2003). Without an artificial airway and ventilatory support Mrs James would have struggled to breathe adequately and the potential to become in respiratory arrest. Within scenario B, Mr James had suffered multiple rib fractures causing difficulty in expansion of his lungs. Fractured ribs are amongst the most frequent of injuries sustained to the chest, accounting for over half of the thoracic injuries from non-penetrating trauma (Middleton, 2003). When ribs are fractured due to the nature and site of the injury there is potential for underlying organ contusions and damage. The consequence of having a flail chest is pain. Painful expansion of the chest would result in inadequate ventilation of the lungs resulting in hypoxia and retention of secretions and the inability to communicate effectively. These combined increase the risk of the patient developing a chest infection and possible respiratory failure and potential to require intubation (Middleton, 2003).

The key issue of Intensive Care is to provide patients and relatives with effective communication at all times to ensure that a holistic nursing approach is achieved.

Intensive care nurses care for patients predominantly with respiratory failure and over the years have taken on an extended role. They are expected to examine a patient and interpret their findings and results (Booker, 2004). In these situations patient requires supportive treatments as soon as possible. Intensive Care nurse should have the ability and competence to carry out a physical assessment and collect the patients’ history in a systemic, professional and sensitive approach. Effective communication skills are one of the many essential skills involved in this role.

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As an Intensive Care nurse, introducing yourself to the patient as soon as possible would be the first step in the history and assessment taking process (Outlined in Appendix A). Whilst introducing yourself there is also the aim to gaining consent for the assessment where possible, in accordance with the Nursing and Midwifery Council’s Code of Professional Conduct (NMC, 2008). Conducting a comprehensive clinical history is usually more helpful in making a provisional diagnosis than the physical examination (Ford, 2005). Within Intensive Care the Airway, Breathing, Circulation, Disability, Exposure/Examination (ABCDE) assessment process is widely used. It is essential for survival that the oxygen is delivered to blood cells and the oxygen cannot reach the lungs without a patent airway. With poor circulation, oxygen does not get transported away from the lungs to the cells (Carr, 2005). The ABCDE approach is a simple approach that all team members use and allows for rapid assessment, continuity of care and the reduction of errors.

Communication reflects our social world and helps us to construct it (Weinmann & Giles et al 1988). Communication of information, messages, opinions, speech and thoughts are transferred by different forms. Basic communication is achieved by speaking, sign language, body language touch and eye contact, as technology has developed communication has been achieved by media, such as emails, telephone and mobile technology (Aarti, 2010). There are two main ways of communication: Verbal and non verbal.

Verbal communication is the simplest and quickest way of transferring information and interacting when face to face. It is usually a two way process where a message is sent, understood and feedback is given (Leigh, 2001). When effective communication is given, what the sender encodes is what the receiver decodes (Zastrow, 2001). Key verbal features of communication are made up of sounds, words, and language. Mr James was alert and orientated and had some ability to communicate; he was breathless due to painful fractured ribs which hindered his verbal communication. In order to help him to breath and communicate effectively, his pain must be controlled. Breathless patients may be only able to speak two or more words at a time, inhibiting conversation. The use of closed questions can allow breathless patients to communicate without exerting themselves. Closed questions such as “is it painful when you breathe in?” or “is your breathing feeling worse?” can be answered with non verbal communication such as a shake or nod of the head. Taking a patients history in this way can be time consuming and it is essential that the clinician do not make assumptions on behalf of the patient. Alternatively, encouraging patients to use other forms of communication can aid the process. Non verbal communication involves physical aspects such as written or visual of communication. Sign language and symbols are also included in non-verbal communication. Non verbal communication can be considered as gestures, body language, writing, drawing, physiological cues, using communication devices, mouthing words, head nods, and touch (Happ et al:2000, Alasad:2004). Body language, posture and physical contact is a form of non verbal communication. Body language can convey vast amounts of information. Slouched posture, or folded arms and crossed legs can portray negative signals. Facial gestures and expressions and eye contact are all different cues of communication. Although Mr. James could verbally communicate, being short of breath and in pain meant that he also needed to use both verbal and non verbal communication styles.

A patient’s stay in Intensive Care can vary from days to months. Although this is a temporary situation and many patients will make a good recovery, the psychological impact may be longer lasting (MacAuley, 2010). When caring for the patient who may be unconscious or sedated and does not appear to be awake, hearing may be one of the last senses to fade when they become unconscious (Leigh, 2000). Sedation is used in Intensive Care units to enable patients to be tolerable of ventilation. It aims to allow comfort and synchrony between the patient and ventilator. Poor sedation can lead to ventilator asynchrony, patient stress and anxiety, and an increased risk of self extubation and hypoxia. Over sedation can lead to ventilator associated pneumonias, cardiac instability and prolonged ventilation and Intensive Care delirium. Delirium is found to be a predictor of death in Intensive Care patients (Page, 2008). Every day a patient spends in delirium has been associated with a 20% increase risk of intensive care bed days and a 10% increased risk of morbidity. The single most profound risk factor for delirium in Intensive Care is sedation (Page, 2008) Within this stage of sedation or delirium it is impossible to know what the patients have heard, understood or precessed. Ashworth (1980) recognised that nurses often failed to communicate with unconscious patients on the basis that they were unable to respond. Although, research (Lawrence, 1995) indicates that patients who are unconscious could hear and understand conversations around them and respond emotionally to verbal communication however could not respond physically. This emphasises the importance and the need for communication remains (Leigh, 2001). Neurological status would unavoidably have an effect on Mrs James’s capacity to communicate in a usual way. It is therefore important to provide Mrs James with all information necessary to reduce her stress and anxieties via the different forms of communication. For the unconscious patient, both verbal communication and non verbal communication are of importance, verbal communication and touch being the most appropriate. There are two forms of touch (Aarti, 2010), firstly a task orientated touch – when a patient is being moved, washed or having a dressing changed and secondly a caring touch – holding Mrs James hand to explain where she was and why she was there is an example of this. This would enhance communication when informing and reassuring Mrs James that her husband was alive and doing well. Nurses may initially find the process of talking to an unconscious patient embarrassing, pointless or of low importance as it is a one way conversation (Ashworth, 1980) however as previously mentioned researched shows patients have the ability to hear. Barriers to communication may be caused by physical inabilities from the patients however there are many types of other communication barriers. A barrier of communication is where there is a breakdown in the communication process. This could happen if the message was not encoded or decoded as it should have been. If a patient is under sedation, delirious or hard of hearing verbal communication could be misinterpreted. However there could also be barriers in the transfer of communication process as the Intensive Care environment in itself can cause communication barriers. Intensive Care can be noisy environment (Newmarch, 2006). Other barriers can simply include language barriers, fatigue, stress, distractions and jargon. Communication aids can promote effective communication between patient and clinician. Pen and paper is the simplest form of non verbal communication for those with adequate strength (Newmarch, 2006). Weakness of patients can affect the movement of hands and arms making gestures and handwriting frustration and difficult. Patients may also be attached to monitors and infusions resulting in restricted movements which can lead to patients feeling trapped and disturbed (Ashworth, 1980). MacAulay (2010) mentions that Intensive Care nurses are highly skilled at anticipating the communication needs of patients who are trying to communicate but find the interpretation of their communication time consuming and difficult. The University of Dundee (ICU-Talk, 2010) conducted a three year multi disciplinary study research project to develop and evaluate a computer based communication aid specifically designed for Intensive Care patients. The trial is currently ongoing, however this may become a breakthrough in quick and effective patient – clinical and patient – relative communication in future care.

This assignment has explored communication within Intensive Care and reflected upon previous experiences. Communication involves both verbal and non verbal communication in order to communicate effectively in all situations. Researching this topic has highlighted areas in Intensive Care nursing which may be overlooked, for example ventilator alarms and general noise within a unit may feel like a normal environment for the clinians however for patients and relatives this may cause considerable amounts of concern. Simply giving explanations for such alarms will easily alleviate concerns and provide reassurance. From overall research (Alasad: 2004, Leigh: 2001, MacAuley, 2010: Craig, 2007) Intensive Care nurses believed communication with critically ill patients was an important part of their role however disappointedly some nurses perceived this as time consuming or of low importance when the conversation was one way (Ashworth, 1980). Further education within Intensive Care may be required to improve communication and highlight the importance of communication at all times. Communication is key to ensuring patients receive quality high standard care from a multidisciplinary team, where all members appreciate the skills and contribution that others offer to improve patients care.


more so in healthcare. It forms the basis of development and adaptation in the healthcare world, and allows professions to merely ‘observe change’ (Griffiths, 2009). This essay critically appraises a research article, Using CASP (critical appraisal skills programme, 2006) and individual sections of Bellini & Rumrill: guidelines for critiquing research articles (Bellini &Rumrill, 1999). The title of this article is; ‘Clinical handover in the trauma setting: A qualitative study of paramedics and trauma team members.’ (Evans, Murray, Patrick, Fitzgerald, Smith, Cameron, 2010). Many research articles are appraised due to the sheer degree of information obtainable in health care settings. Critically appraising articles allows one to filter out the low quality studies and distinguish misleading information (Cormack, Gerrish & Lacey, 2010).

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The article title clearly explains the research, without being too extensive, using extraneous words or explaining the results found. It is able to inform the reader of the research aim without becoming uninteresting. The basic concept of a title should provide a summary of the content. A good title should be straight forward; a poorly written title will defer readers (Centre for research writing resources, 2012). Key words serve as key elements in the article, including handover, trauma and paramedics. Again allowing the reader to know precisely what the article consists of.

The abstract of this article elucidates the purpose of the research, its results and reasoning’s. It also briefly articulates the method, highlighting key factors necessary. Everything declared in the article is present in the central text; all statistics and findings are indistinguishable. The abstract enables the reader to decipher if the article is of interest.

This article clearly identifies the aims of the research in the abstract and main text. By using aims, the results and discussion are simply interpreted and flow effortlessly. Aims should be written plainly, in non-technical language and state the concepts the research is addressing (Stommel & Wills, 2004). By using comprehensible and concise aims, the reader can simply understand what the researcher is setting out to obtain, giving the research a focus. In the background of the article, the researcher clearly identifies the relevance of the research aims and why the research is required, including medical mishaps and misinterpretation of trauma handovers. This allows one to understand the concepts behind the research, give the aims credibility and support incorporation into the results. Background information suggests that the topic has been thoroughly researched and aids construction of research methods and aims (Blaxter, Hughes & Tight, 2006).

This research uses qualitative methods, which deem appropriate for this type of research, as the researcher is trying to highlight the attitudes, experiences and emotions of participants concerning handovers. The research does not use statistics, rather participant’s responses and their subjective experiences around the topic. Qualitative research looks at the essence of social phenomena, giving people the opportunity to understand what people do and why (Williams, 2010).

In the abstract, the researcher articulates using grounded theory and thematic analysis. Grounded theory is used to develop theories that can be used in practice (Oktay, 2012), suggesting this is a desired method for this research. The article is well set out, permitting the research design to be effortlessly recognisable and easily read. Although the researcher states that grounded theory was used, one may say that it was used incorrectly. Grounded theory is used to create theories that can be applied in real life situations (Oktay, 2012) and although this study does create a theory, (effective and ineffective handovers) it is building on an already established theory (MIST Mechanism-Injuries-Signs-treatment). The use of grounded theory is very ambiguous in this research; it could be argued that is has been applied correctly, due to using current research to guide the study. Whether it was applied accurately or not, the researcher has not explained how they used grounded theory or integrated the theories into the research. The researcher does not disclose how they determined the exact method used. This would be beneficial as the research question, method of data collection and data analysis all depend on each other, and therefore these paramount decisions need to be made continually throughout the research process (Willig, 2008).

The participants were selected through purposive convenience sampling, with no incentives. Although this is convenient for the researchers, it may mean the respondents are not the most appropriate to the task itself (Burnard & Newell, 2011). In this case, all the participants were Paramedics or part of a trauma team and all had understanding with trauma cases. As the researcher states in the limitations, the conclusion may be different for less experienced participants or those who were trained differently. There is no explanation as to why the participants chose to take part in the study, nor why others chose to decline the opportunity. This would be valuable information as there may be a specific group of people that decide to volunteer for research studies, therefore the research may not be applicable for all paramedics and trauma staff. One may find it difficult to consider how all of the volunteers happened to be experienced, this may lead to the suggestion that the researchers filtered through the respondents and chose the most suitable, still using convenience sampling. The article is also unclear about how the volunteers came to know about the research and what they were told before the research commenced. Convenience sampling is most commonly used in larger- scale studies (Sim & Wright, 2000) and therefore seems an outlandish method to use, as only 27 participants were used in this study.

In this article, the researcher does not disclose the setting in which data was collected. This may well have an impact on the results, as it could influence the participant’s emotions, how comfortable they feel and how much information they are willing to provide (Shi, 2008). Also, they do not specify which researcher conducted the interviews. By the interviewer being a Paramedic, part of a trauma team or neither may have an ‘interviewer affect’ (Alder & Clark, 2011). This in turn may change the results of the study, make it bias or unreliable. There is an obvious section in the article relating to how the data was collected. All participants were interviewed face to face, but the researcher does not specify if these were in groups or individual. By interviewing as a group some people may conform to others responses. Using a semi-structured face to face interview allows the interviewer to observe non-verbal communication techniques, as well as how the participants give their responses (Flick, 2009). The interview consisted of pre-determined questions, using a topic guide. It is not discussed who wrote the topic guide, this again could have an effect on the results or the way in which certain questions are worded. The paramedics were given a somewhat different question format to those of the trauma team, allowing the researchers to gain full potential of questions given. The topic guide was integrated into the article, so readers are fully aware of questions asked. The participants were given a copy of MIST and asked to comment on how it could be enhanced. This was modified and presented at the specialties’ clinical meetings and opinions were given to the researchers by email or telephone. The researcher does not specify who was present at the clinical meetings, and whether the Paramedics were given the opportunity to see the modified version. It also does not disclose how long participants were given to respond and if they were given a chance to confer with any other people. If the participants were able to discuss the modified MIST before replying, the results may be inaccurate; some responses may be influenced by other professions with different experiences. The article is very vague about who was interviewed on the minimum dataset for handovers, as only the speciality groups were declared. This could cause a bias result, if only one profession was interviewed on specific aim. The researcher has not commented on their rationale for using any of these methods; supplying a rationale can help ensure validity in the research process and results (Piekkari & Welch, 2004).There is no mention of any changes made throughout the study, therefore one can assume the original plan was followed through the majority of the study. The researcher has not mentioned how the data was recorded; this could have a detrimental effect on the results, because if they are noted from the researcher’s memory, mistakes could be made. Grounded theory usually records data using audio and video tapes, allowing the researcher to carefully examine responses given (Schreiber & Stern, 2001).

At no stage in the article does the researcher comment on their own role and any bias they may cause in the study. Researchers are said to be bias when they do not take an objective approach to research (Powers & Knapp, 2006). From the article itself one can see that the research team consists of 1 Ambulance service employee, 1 trauma team member and 4 people from the research centre of excellence, suggesting there is minimal bias from researchers, but this is not documented. One may say bias was reduced as the participants were not given MIST until after they had been asked some of the questions; therefore it had no influence on previous responses. There is no research question used in this study, but there are four clear aims that were derived from the extensive background and initial research.

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Ethical issues have been considered by the research team as the study was approved by an ethics committee, but there is no justification of ethical issues taken into consideration concerning the participants. Although there are no ethical issues relating to the welfare of the participants, the researchers do not explain confidentiality and informed consent. One can presume that informed consent was gained from each respondent as they volunteered for the research. Informed consent requires the participants to have adequate information regarding the research (Surrena,2011).

During this study, the data was sufficiently analysed, using thematic analysis. Thematic analysis uses coding to identify the recurrent or main themes in research results. It is most often used in qualitative research as it emphasises recurrent ideas and feelings (Mays, Popay & Pope, 2007). By using a coding programme to categorise responses from participants, the researchers were able to find recurrent themes and were capable of placing responses into three nodes that were directed by the initial aims. This was independently checked for consistency and in some cases a third researcher was used to decipher any discrepancies, again reducing bias. In the main text, the researcher does not mention the use of thematic analysis, only the coding process, although it is mentioned in the abstract; one can assume this method was used throughout. It is not explained why the responses shown in the article were chosen to be published, but there is a descriptive table shown that entails several responses. It is exceedingly supportive to the results given, as it concurs with the results and highlights how the paramedics and trauma team share equivalent experiences with trauma handovers. The data analysis materialized no contradictory responses; there was a general consensus between all participants, emphasizing the need for further research and handover training and frameworks.

There is a clear consensus that countless handovers are ineffective and several participants agreed on reasons for this. This was evidently stated by the researcher, along with the need for paramedics to obtain training in effective, concise handovers. There is no evidence for argument as all participants agreed that handovers needed to be enhanced in order to improve patient outcome and quick treatment. The researchers were not trying to settle argument, merely emphasise the experiences of professionals in the emergency setting. The researcher considers triangulation, but declares it should be used with caution in other hospitals, not mentioning the study’s use in other ambulance services. Triangulation refers to approaching data from various perspectives (Flick, Kardorff & Steinke, 2004).The discussion is flawlessly set out as the aims the researcher set out to justify. This makes it easier to alternate between the method, results and discussion with ease.

The researcher discusses how the study can be the basis to further development with trauma handovers and illuminates the need for further research and application. It does mention the need for further paramedic training, but as a lone piece of research, it is unable to act upon this. The research has not highlighted any new areas that need investigation or further research, but has merely emphasised the awareness of poor trauma handovers. There is also no mention of transferability in this study, other than using it cautiously in other hospitals. Transferability refers to the probability that the study has meaning or use in other situations (Surrena, H 2011). In addition, there is a short time period between the article being written and it being published; meaning the information in this study is relevant and up to date.

In conclusion, this research study is well designed with meaningful and useful results. The aims and background information are impeccable, giving the researcher ample reasons to conduct the study. The results are well analysed and supported by the discussion. The only downfall to this article is the minimal justification of choices made throughout the study. There are various limitations, that the researchers have identified themselves, allowing further researchers to replicate the study, modifying the limitations noted in this article. Due to the researcher identifying the need for further research, the reader may not consider changing their current practice based on this article alone. However it would be exceptionally useful in further research.


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